Laparoscopic Segmental Resection for a Tumor in the Angle of Treitz: A Case Report and Surgical Video

Introduction: The angle of Treitz is defined as an intestinal loop between the third duodenal portion and the proximal 10 cm of the first jejunal loop.1,2 Owing to the rarity of small intestinal tumors and the even rarer occurrence of tumors in the angle of Treitz, there is no definitive treatment. Segmental resection is often performed by laparotomy, but laparoscopic segmental resection is a technically challenging procedure that has been rarely reported.3 Case Presentation: The patient was a 63-year-old man. His medical history was anemia noted during a physical examination, and a tumor in the angle of Treitz was detected by computed tomography of the abdomen. The pathologic diagnosis of the tumor was not known before surgery, but gastrointestinal stromal tumor was suspected. Materials and Methods: The patient was placed in a supine position and five ports were placed. First, we found the tumor with surface vascular growth in the jejunum within 10 cm from the angle of Treitz. We started by dissecting the mesentery near the tumor and proceeded in the direction of the ligament of Treitz, and planned to perform the resection 10 cm from the jejunal origin. Kocher mobilization was performed from the patient's left side, and the ligament of Treitz was dissected and opened. Dissection proceeded in the anterior layer of the inferior vena cava, and gauze was placed there. The duodenum was mobilized from the patient's right side. We reached the gauze that had been placed earlier. The oral side of the jejunum then was pulled out to the right side through the ligament of Treitz. The 2 cm location on the oral side of the tumor was marked as the line of dissection, and resection was performed using a stapling device. The reconstruction procedure was then performed by side-to-side duodenojejunostomy. The insertion hole of the stapling device was closed with consecutive sutures. Results: The operative time was 297 minutes with blood loss of 100 mL. There was no postoperative complication and the patient was discharged 12 days after surgery. The histopathologic diagnosis was gastrointestinal stromal tumor and the surgical margin was negative. Conclusions: Laparoscopic segmental resection appears to be a safe treatment option for tumors in the angle of Treitz. Compliance with Ethical Requirements: This study was conducted in accordance with the Declaration of Helsinki and the ethical guidelines of the Ministry of Health, Labour, and Welfare of Japan for clinical studies. Consent for Publication: Written informed consent was obtained from the patient for the publication of this case report. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Funding: This study did not receive any funding. The authors declare no conflicts of interest in association with the present study. Runtime of video: 9 mins 52 secs